Amid increasing concerns for the life of Isa Muazu, who is on hunger strike in Harmondsworth immigration removal centre, it has emerged that the Home Office has an ‘end of life plan’ for the Nigerian failed asylum seeker. A source at Harmondsworth told the Guardian that detention staff had been warned to "expect a hunger striker to die".

Muazu’s situation is a complex one. As well as hepatitis B, kidney problems and stomach ulcers, an independent doctor has found him to have psychosis and severe depression. Muazu began his hunger strike because he felt that his health needs and dietary requirements were not being met in detention. In October, the high court refused his release on medical grounds. His case is one of several controversies surrounding the welfare of those held in the UK’s removal centres.

Image Yarl's Wood, Oliver White, Creative Commons

In 2012 it was found that Rule 35 of the 2001 Detention Centre Rules, which prevents the locking up of victims of torture, was routinely contravened. Poor conditions and allegations of sexual abuse came to light earlier this year in a report by the Independent Monitoring Board on Yarl’s Wood Removal Centre in Bedfordshire. The Home Office’s approach to ‘food and fluid refusers’ is the concern for Muazu at this time.

In a recent briefing to the Home Office, the campaigning group, Medical Justice, noted a letter that was sent to Immigration Removal Centre managers in July, asking that they ensure that doctors ‘should not state that someone is not fit to be detained rather they should advise on the consequences of detention in terms of medical conditions’. Although, the letter may have been subsequently withdrawn, Medical Justice remain concerned about the medical needs of those on hunger strike in detention centres and the inconsistent messages to doctors. The group has pointed out that ‘when a doctor says “fit for detention” or is silent on the issue, that seems to be accepted without question and detention maintained but when a doctor says unfit for detention, not only is further information requested, but now the Home Office is telling doctors not to say this at all.’

In Muazu’s case there is a blurring of physical, psychological and social distress that makes it especially difficult to ascertain the extents of his mental capacity and the consequences of different forms of pain and suffering. Under the Mental Capacity Act 2005 anyone over the age of 18 years has the legal right to refuse food and/or fluid. Regardless of his mental illness, Muaza's situation raises the matter of 'total pain' that is central to hospice and palliative care and the Government's End of Life Care Strategy. Total pain recognises that pain is physical, psycho-social and spiritual.

Muazu sought asylum in the UK because he felt that his life had been threatened in Nigeria by Boko Haram, an Islamist group with a history of violent extremism. Mauzu came to the UK on a visitor’s visa in 2006. He overstayed his visa and survived as an undocumented migrant in London until he applied for leave to remain in 2011. It is hard to imagine that this series of events and the precarious living that was entailed were not emotionally and physically challenging, if not traumatic, particularly for someone with mental health problems.

It is these aspects of Muazu’s life that can be understood with regard to the idea of total pain and experiences of being an undocumented migrant. Muazu may have taken the decision to go on hunger strike as a protest, but his response bears a close resemblance to another psychiatric condition that has been emerging in child migrants. I first came across this condition in the doctoral research of Erika Sigvardsdotter. During her ethnographic fieldwork in Sweden, Sigvardsdotter met a migrant family with three children, aged between ten and eighteen. The once lively children were lying unresponsive in their beds. They were being fed through naso-gastric tubes and were incontinent. The family was on the verge of becoming undocumented. Erika Sigvardsdotter describes what she saw,

The children in this family were all in bed. At first they stopped goingto school. Then they stopped going out. They ate less. Then they kept totheir rooms, after a while to their beds. They had one by one, step by step…shut themselves away from the world. By the time we visited them,two of the children were completely withdrawn from the world, silent,still and completely unresponsive. They were fed gruel three times a daythrough a naso-gastric feed.

Image Unicef

Pervasive Refusal Syndrome is a condition that was first identified by Swedish child psychiatrists and pediatricians among refugee children in 2003. At that time more restrictive criteria were being applied to the granting of asylum status.

The condition was first dubbed ‘Giving Up’ and ‘Apathetic Refugee Children Syndrome'. It was diagnosed in 424 children of asylum-seekers in Sweden in 2004. The phenomenon is now more commonly recognised as a part of Pervasive Refusal Syndrome ‘a profound and pervasive refusal to eat, drink, walk, talk or care for themselves in any way over a period of several months’. Clinical research suggests that the devitalisation of PRS is a response to psychological trauma and chronic stress, conditions thought to be exacerbated by the uncertainty and limbo of undocumentedness.

The criminalisation and detention of those seeking asylum in the UK - people who may have already endured trauma – has long been recognised as ethically dubious. The growing medical evidence of the detrimental health impacts and trauma of undocumented migration adds another layer to current debates. For example, what are the bio-psycho-social relationships between Pervasive Refusal Syndrome seen as an unconscious response to trauma and the actions of a hunger-striker in a detention centre? Might these relationships provide a new understanding not only of the effects of pain but also of notions of 'choice' and volition?

The suggestion that we should "expect a hunger striker to die" is deeply disturbing. It fails to recognise the extents to which traumatic pasts and the experience of undocumented migration can take their toll upon vulnerable people.

Time is running out for Isa Muazu. We can only hope that when the judgment is delivered on his case this week that it shows some regard for the entangled and spiraling conditions that have brought him to this point.

Post Script

1. On the 21 November Isa's appeal for temporary release from Harmondsworth was not successful.

3. Isa was deported from the UK on a privately chartered plane on the 29 November. Nigeria refused to allow the plane to land and Isa was subsequently brought back to the UK and detained in the medical wing at Harmondsworth. A vigil was held by Isa's supporters outside the Home Office on the 3rd December.

4. On the 17th December Isa was deported to Nigeria and his supporters say that he was not taken to hospital and went into hiding.

Case Stories

Case stories is a transdisciplinary project on migration, dying and care. Using oral histories, stories and art, the aim is to better understand the pain of social exclusion, inequality and injustice at the end of life. The site is developing with the project.